|Home | About | Journals | Submit | Contact Us | Français|
In Peru, commercial sex involving men and male-born travestis, transgenders and transsexuals (CSMT) is usually represented as a dangerous practice carried out on the streets by people experiencing economic hardship and social exclusion. However, in reality little is known about the complexities of this practice in Peru. This paper presents findings from an ethnographic study of the characteristics, patterns and socio-cultural aspects of CSMT in three Peruvian cities. The study included participant observation in sex work venues and interviews with 42 sex workers and 25 key informants. We found that CSMT in Peru takes many forms (some not previously described in the country) and is practised in different places by people from various socioeconomic levels. In many cases, the practice appears linked to ideals of social mobility, migratory experiences and other economic activities. In addition, the increasing use of the internet and mobile phones has changed patterns of sex work in Peru. We review the implications of these findings for future research and public health interventions.
Commercial sex involving men and male-born travestis, transgenders and transsexuals (henceforward referred to as CSMT or commercial sex between men and trans people) is a subject of continued academic interest. This interest grew in the 1980s after the advent of the AIDS epidemic (Aggleton 1999; Bimbi 2007). In a review of social science research on the sex trade, Vanwesenbeeck (2001) has detailed how the first approaches to male prostitution considered this phenomenon a form of social pathology, often described as a dangerous behaviour exposing people to disease, violence, discrimination, criminalisation and exploitation (Kaye 2007; Scott et al. 2005). These perspectives are still present today, but more nuanced views of CSMT have emerged recently, with many scholars suggesting that social and sexual practices, as well as the vulnerability of subjects who provide sexual services are influenced in complex ways by socioeconomic factors, gender ideologies, power relations, social norms and culture (Aggleton 1999; Bimbi 2007; Bimbi and Parsons 2005; Browne and Minichiello 1996; Calhoun 1992; Kaye 2003; Perlongher 1999; Prestage 1994; Scott et al. 2005; Van der Poel 1992).
Although not legally criminalised in Peru, CSMT is highly stigmatised. In popular Peruvian stereotypes, the practice is usually associated with poverty, crime, and immorality, and perceived to be carried out on the streets by socially marginalised people (Cosme et al. 2007). Concern about spread of epidemics of HIV and other sexually transmitted infections (STI) has focused scientific interest upon homosexual practices and CSMT (Bautista et al. 2004; Clark et al. 2007; Konda et al. 2008a, 2008b; Lama et al. 2006; Montano et al. 2005; Paris et al. 2001; Salazar and Silva Santisteban 2009; Sanchez et al. 2007; Tabet et al. 2002; Valderrama et al. 2008). Some studies have examined the socio-cultural context of compensated sex (Fernandez-Davila et al. 2008; Salazar et al. 2005, 2006), sex work within the framework of male sexual cultures (Caceres and Jimenez 1999; Caceres and Rosasco 1999, 2000), and social vulnerability and violence associated with CSMT (Caro 1999). Certainly, the research objectives of studies are diverse and CSMT is not always their main focus, but some reports offer some clues that allow us to infer that the CSMT is more complex and varied than usually thought from public policy and popular stereotypes, both by the different sexual identities of those who offer sexual services (Konda et al. 2008a), as well as the places and ways in which it is practised (Bayer et al. 2010; Caceres and Jimenez 1999). In any case, the complexities and diversity of CSMT have not been described or captured in most previous studies in Peru on this topic, which generally focus on populations of individuals who offer sexual services in public places and suffer social exclusion (such as poor youth and members of sexual minorities).
This situation has some problematic aspects: On the one hand, a partial view of sex work may limit the efficacy of social and health promotion interventions, which will not be able to reach potentially vulnerable but invisible sex workers. On the other hand, public discourses and images on CSMT can reproduce stigmatising views of sex workers, based on scientific information which only present data on marginalised subjects (Tiby 2003; Van der Poel 1992).
The present study is based on an in-depth approach to men and male-born trans individuals who perform sex work. We obtained their individual stories and examined the economic and socio-cultural context in which they live and operate. Our objective was to identify, describe and analyze the social and cultural factors related to the practice of various forms of CSMT among subjects of different social backgrounds. We intentionally did not focus on any one particular group of sex workers, but rather examined CSMT in its multiple manifestations in different groups and social contexts.
We conducted an exploratory, ethnographic study. Fieldwork was carried out from January to October, 2009 in the cities of Lima, Pucallpa and Iquitos, Peru, which were selected because of the high levels of STI and HIV risk behaviours previously found in these contexts (Lama et al. 2006; Tabet et al. 2002).
Lima, the capital of Peru, has a population of around nine million people (about one third of the country’s total population) comprised mostly of descendants of immigrants and their parents who arrived from throughout the country and settled in the city during the last sixty years. The bulk of Peru’s businesses, industrial activity, services and cultural affairs are concentrated in Lima and it additionally receives an important share of the revenue generated by the extraction of natural resources in other parts of the country.
Pucallpa and Iquitos are the capitals of the Amazonian regions of Ucayali and Loreto, respectively, located in the North-Eastern region of the country. Native ethnic groups living in these areas speak over 40 languages, but the urban centres have a major presence of Spanish-speaking mestizos (population of mixed race). Extractive activities (wood and oil) and trade dominate the regional economies. The city of Pucallpa, with a population of approximately 200,000 habitants, is a meeting point for many migratory flows mainly associated with commerce and logging, and to a lesser extent, agricultural and industrial activities. Iquitos, with approximately 400,000 habitants, is accessible only by air or river, and has greater economic diversity than Pucallpa.
We used ethnographic, observational techniques to analyse public behaviour and the physical and social context in 52 sex work venues identified by previous mapping of the three cities noted above. Two experienced Peruvian ethnographers (CRN and MZ) visited these places, sometimes with the support of health promoters and other key informants who facilitated access. In most places, the research team engaged in informal interactions with sex workers, managers and employees of establishments, and other persons familiar with the activities of sex workers, including some clients. In other cases, the ethnographers just observed and took notes, for example in public places where their presence may have compromised the confidentiality or security of sex workers. After each visit, the ethnographers discussed and compared their observations and fieldwork notes before preparing a report for further analysis.
We also conducted in-depth, semi-structured interviews with 42 subjects who provided sexual services (20 in Lima, 11 in Iquitos, and 11 in Pucallpa). They were selected in each city by the researchers either directly during the field work using snowball technique, with the support of health promoters, or by searching sexual services advertisements in print and electronic media, to obtain a convenience sample of maximum variablility. The selection criteria for recruiting interview participants were: being a male or male-born trans; being at least 18 years of age; having a history of offering sexual services to men in exchange for money within six months prior to study participation (the commercial character of the exchange was explicit to both sex workers and clients, with payment made either before or after sexual services were provided); and giving verbal consent to participate in the study. Confidential, anonymous interviews, lasting 60–90 minutes, were conducted in private locations. Subjects were asked to narrate their life stories highlighting their experiences, attitudes and opinions related to the practice of sex work, and were also questioned about other forms of commercial sex they knew or practised themselves. At the end of the interviews, participants were financially reimbursed for transportation costs.
Sex workers interviewed were between 18 and 45 years of age (mean age, 27) and had different characteristics in terms of socioeconomic background, sexual identity, time and experience in the sex trade, and places and modalities of CSMT. Educational level was our primary indicator of socioeconomic status (SES: low, low-middle, middle, and upper-middle), but was adjusted for monthly income (as compared with the legal minimum salary in Peru (approximately US$ 200 per month, 2010), and occupation (sex work as an occasional or frequent activity, and alternate jobs.)
In each of the three cities we also conducted open-ended interviews with 25 key informants: managers and employees in entertainment establishments, health promoters, sexual rights activists, health professionals, and researchers in sexuality and public health. They were asked to share their knowledge and perspectives on CSMT.
Field notes obtained through observation in the sex work venues and audio files of the interviews were transcribed verbatim into word-processing files. Data was coded and organised following a grounded-theory approach (Strauss and Corbin 1998) using the computer program Atlas.ti™. The information presented here is based on triangulation and contrasts between our different sources of data (fieldwork observation, interviews with sex workers and key informants). The study protocol was reviewed and approved by the Institutional Review Boards of IMPACTA and the University of Washington.
CSMT in Peru occurs in many different venues. During our field work, in addition to on the streets, we found sex work was also performed in bars and discos, saunas, sex cinemas and video clubs, lodges (hotels and hostales), houses and apartments (of individuals, groups or agencies), night clubs, brothels, prisons, river boats, semi-rural areas around cities, highways, and timber and oil industry camps (see Table 1). A variety of strategies were used to locate and contact clients: face-to-face methods, intermediaries, various forms of internet-based sex work, and through mobile phones and the print media.
The most visible and well-known forms of CSMT were those involving travestis and fletes working on the street. In Lima and Pucallpa, some travestis worked also in specific peri-urban areas near roads or highways. In the context of the sex work in Peru, the term travesti is used to refer to individuals born male but with the appearance, attitudes or identities of women (independently of whether they see themselves as transsexuals or trangenders). Their clients are mostly men who self-identify as heterosexual. In the streets, contacts are negotiated regarding price, location and other details of sexual services, such as sex roles, time, condom use, etc. Almost all the travestis described clients asking to be penetrated. Although some travestis agreed to do this (charging a higher rate), some others strongly rejected it.
Fletes are young men with different sexual identities and social backgrounds. Most assume masculine attitudes in their public behaviour and define themselves as heterosexual or bisexual, but there are also some fletes who have more feminine manners and self-identify as gay or homosexual. Unlike travestis, fletes do not dress in female clothes. Fleteo is the systematic exchange of sex for money (Caceres and Jimenez 1999), and includes negotiations similar to those seen among travestis. For some young men, fleteo is a regular job, while for others it is a temporary or occasional activity. Fletes typically work along specific streets or in public squares, bars, discotheques and gay porn cinemas of Lima. In these places we also found groups of soldiers, or cachaquitos, as they are known. They are recruited by the Peruvian Army from diverse parts of the country, but in their time off some may frequent gay venues in central Lima where they may receive proposals of sex for money, food, drink or overnight lodging. The clients of fletes and cachaquitos are mostly gay men, bisexual men and closeted homosexuals of different social classes.
Many travestis and fletes perform street-based sex work in highly competitive environments (for clients, working areas, power and prestige, etc.) and frequently encounter violence from other sex workers, pimps, street delinquents, and even public safety officials. However, in the three cities we also encountered some fletes and travestis offering sexual services in places and modalities not necessarily associated with violence.
In Iquitos, fleteo was similar to fleteo in Lima, with low-income youth seeking clients in squares, tourist areas, clubs and gay bars. The demand for sexual services here was more clearly associated with tourism and the local gay subculture. In Pucallpa, unlike in Lima and Iquitos, it was difficult to identify fletes in the streets. In the main square, encounters occurred between men that led to sex for money, tips or invitations to eat or drink liquor, but without the negotiation pattern of fleteo seen in Lima and Iquitos. Some young men were familiar with the gay scene and self-identified as fletes, but offered their services only in gay clubs and bars, using group strategies to contacting clients and offer protection.
In some gay entertainment establishments in the three cities there are also mozos (“waiters”) and anfitriones (“hosts”) who interact with clients and may have sex for money in nearby hotels or even inside the establishments, usually with the agreement of the manager of the establishment.
In Lima, a special type of entertainment venue known as video porno combines the characteristics of a discotheque and bar, with cuartos oscuros (dark rooms) for erotic interaction and anonymous sex, television screens showing sexual images, and private cabinas or small rooms where it is possible to watch pornographic movies and have sex. Some of these venues also have anfitriones or mozos, and fletes may also visit such places to find clients.
In some porn cinemas in Lima we witnessed travestis who roamed the halls to contact their clients (mostly heterosexually-identified men) during the screening of heterosexual sex scenes. These travestis worked under arrangements with the managers of the cinemas, who provided security and rooms for sex services on the premises.
Another sex venue encountered only in Lima was gay saunas. Masseurs who worked in these establishments provided massage to clients from middle and upper middle class. These masseurs were mostly young men self-identified as heterosexual or bisexual and offered massage services which could lead to sexual services performed in the same massage rooms.
Some men and travestis in Lima and Iquitos worked for intermediaries or agencies that received telephone requests from clients asking for a male companion or escort. Several of these agencies advertised on the internet or in “relaxation” sections of some newspapers, and charged the sex workers a percentage of the cost of sexual services. This form of sex work also included strippers and exotic dancers. Many of these dancers, in addition to working in nightclubs offering entertainment and shows at private parties, were available for contact by intermediaries or directly by clients to provide sexual services.
In addition, we encountered dancers, masseurs, escorts and many other young men and travestis who used the internet and newspapers, business cards and personal contacts, to work independently of any agency or intermediary. Experienced sex workers reported that in previous decades such contacts were made primarily by escort agencies. However, with growing access to the internet and mobile phones, independent forms of sex work have become more frequent. In fact, most sex workers interviewed reported using mobile phones or the internet to contact clients, and many noted this allowed them to charge higher rates, remain anonymous, have a relatively steady client base, thereby avoiding the danger associated with working on the street.
“I used to work in the street, but now I post my photos online and receive calls on my cell. It’s better … “ (Claudia, 26, travesti, low-middle-SES, Iquitos.)
“I no longer have to return to the streets. There are many raids, fights [between travestis] for the spaces in the park … So I prefer to work solely on cell phone” (Mariela, 30, travesti, middle-SES, Iquitos.)
“Now some [fletes] find clients online. They are not coming anymore to the square” (Rolando, 45, veteran flete, middle-SES, Plaza San Martin, Lima.)
“He [the intermediary agent] has pictures of the strippers in his cell phone. He shows them to clients and says, ‘choose’ “ (Marcelo, 25, stripper, middle-SES, Lima.)
“I have a cell phone and a website. So I am available to clients 24 hours a day, and so I can charge more than on the street “ (Carolina, 21, travesti, private escort, low-middle-SES, Iquitos.)
There are forms of CSMT clearly linked to specific economic activities. For example, some travestis in Pucallpa reported that they occasionally made agreements with the managers of construction projects to provide sexual services to their workers. In Iquitos and Pucallpa, tourism creates a visible demand for commercial sex. In addition, sexual services are offered by men and women during activities related to trade and transport, typically on river boats travelling on the Amazon River, and on roads on the outskirts of Lima.
In the Ucayali region we encountered a very distinct but widespread type of sex trade associated with the logging industry. Thousands of young men, mainly from urban centres like Pucallpa, are hired each year by logging companies and sent deep into the forest in groups of 8 to 30 to work for several months. They live in camps, where there is at least one person hired to prepare meals. This person can be a woman or a young man with a homosexual or feminine identity. Several cocineros (cooks) reported providing sexual favours to loggers. Although these sexual exchanges do not necessarily involve payment, many cocineros have the opportunity to earn additional income from selling sex. They may maintain notebooks with records of the sexual services provided (as in these isolated camps money is absent), and payments are deferred until the end of the work period, when all accrued wages are paid upon return to the city, with the managers of logging companies deducting the payment demanded by cocineros from the salaries of workers – sex services are often listed as “laundry” in the records (see also Nureña et al. 2009).
We encountered similar reports of cocineros offering sexual services in some camps of oil companies in the Loreto region, but sexual transactions at these camps tended to be more clandestine or covert due to the more rigid rules imposed by companies.
The majority of fletes offering sexual services in the streets rationalised their involvement in sex work as a consequence of social exclusion and lack of other job opportunities:
“I started [to offer sexual services] for the necessity: I have a little daughter and … I have no job now. The necessity obliged me to become involved … I needed money” (Edgar, 24, flete, low SES, Lima.)
“When I go [to sell sex], I do it for the money. I really live with this. I cannot do anything else because there is no other job for me” (Manuel, 20, flete, low SES, Iquitos.)
With respect to the travestis, social prejudices and stereotypes restricted many of them to working in jobs such as hairdressing and sex work. For example, one travesti from Lima, who had completed a university degree in social communication, turned to sex work after several unsuccessful attempts to find employment in this field. However, while social exclusion could be an important factor leading to involvement of many travestis in sex work, charging for sex is well accepted among them and sometimes even encouraged through social pressure:
“In the disco I went with a guy and when I returned, my friends [other travestis] asked me, ‘How much have you earned?’ Imagine, everyone said ‘I charge so much’, and I would not say ‘nothing’. They will say ‘you’re going to ruin the business’ … I did not need it financially because I was living with my parents. At first I went out with the boys for pleasure, but to avoid losing face with the chivas [‘goats’, i.e. men with feminine manners] I also began to collect money” (Larissa, 25, travesti, low-middle SES, Iquitos.)
In contrast, among sex workers from the middle or upper-middle classes there were different motivations for entering into sex work. For example, some reported they began offering sexual services out of “curiosity”, as a “hobby” or as a way of finding “adventure” and sexual pleasure. There were also those who saw sex work as a way to meet people from higher social classes – regardless of their sexual identity, and mainly when their opportunities of social mobility were perceived as limited. Others mentioned being influenced by their friends:
“I wanted to live the adventure. A friend [travesti] came from Lima and told me everything she had lived there. That attracted me and I went to Lima with her. I did not see prostitution as something bad. It was a pleasure … I enjoyed it” (Paloma, 30, travesti, low-middle SES, Pucallpa.)
“My friends told me they had sex with gay men. It was then that I wanted to experience it too. It was not for economic necessity [their entry into sex work]. A man wanted to pay me and I couldn’t say no” (Iván, 24, exotic dancer, middle SES, Lima.)
Motivations for performing sex work may vary over time. Some men began to offer sexual services out of curiosity or for pleasure, but then found this provided a good way to earn a significant income. Others entered the opposite way: from the initial need for money, they then turned to sex work for pleasure or habit. There were also those who saw sex trade as a means of working independently and managingtheir own schedule. By comparing this activity with salaried work requiring fixed times and places of work, some participants found sex work preferable to other forms of employment.
“The first time I went [to offer sexual services] I just wanted to feel the experience. But later, when I had the experience and the client paid me, I began to like the money… I liked the money! Since that time I no longer wanted to work as a cook” (Mónica, 28, travesti, low-middle SES, Pucallpa.)
The need for money was often reported by sex workers as a major reason for engaging in commercial sex. However, an analysis of respondents’ social backgrounds and life histories led us to propose that the concept of “economic need” is relative and may be subject to multiple interpretations dependent on social position an socio-cultural context, in which the “need for money” is not always the same as economic hardship. This is not to deny that there are people performing sex work as a means of survival, as this was reported by many individuals from low SES in all three cities. However, for most of the subjects, the desire for money through commercial sex was often strongly linked to ideals of independence, to aspirations of consumption and the lifestyles of the middle-class (as often defined by advertising and mass media), or to the desire to access environments and symbols of prestige of the upper class.
For example, several escorts, masseurs and strippers of middle and upper-middle SES engaged in commercial sex to finance their higher education, or to rent apartments in middle-class or upper middle class districts. Almost all the sex workers, regardless of their SES, used part of the money obtained in commercial sex to purchase consumer goods such as fine clothes, accessories, appliances, etc. Similarly, subjects with different SES (but especially migrants and those from low SES backgrounds) frequently mentioned and valued their access to places and people (clients) from the higher social status.
“I get the money … 300 soles for five minutes [more than US$ 100]. I needed money, but not so much. I got into this business because they [clients] will take you to fancy restaurants, good places … I like these things” (Marcelo, 25, stripper, upper-middle SES, Lima.)
“What I like about this [sex work] is having fun and free drinks. I dance, drink… talk to people, I get to meet other ‘kinds’ of people [educated, distinguished, with money]” (Julio, 23, cachaquito/flete, low SES, Lima.)
“I do it [sex work] because I have to pay for my [professional] studies… Besides, I use the money to pay for my flat, my food, the gym….” (Roberto, 23, stripper, middle SES, Iquitos.)
The life stories of sex workers highlighted the recurrent presence of migratory experiences associated with either debut into sex work or the practice itself. One pattern is that of young men who leave home and begin to offer sexual services due to lack of money, job opportunities, or social support in the new environment. This was reported by many fletes and cachaquitos in Lima.
A different pattern of geographic mobility from that of fletes and cachaquitos was identified among travestis. In our interviews, most travestis reported temporary or permanent migration resulting directly from sex work. The most common situation was that of a young travesti travelling to other cities seeking new sex work markets. This pattern bore a relationship with the demand characteristics, since some clients preferred “new” and younger travestis, as reported both by key informants and travestis.
Mobility also occurred in transitions between different places and forms of sex work. This is another feature common to most sex workers interviewed, who claimed to have offered sexual services in more than one form, and using different strategies to contact clients. For example, some searched for clients on the streets at times, but at other times waited to be contacted by mobile phone to work as private escorts. In an extreme case of versatility, a young man worked in Lima in the afternoons as a flete, and then as a travesti at night to earn more money.
This study in three cities in Peru reveals that sex work is diverse and multifaceted. Contrary to local stereotypes portraying sex work as an obscure and dangerous practice performed mainly on the streets and squares by travestis, fletes or other persons considered socially marginalised or extremely poor, we have shown that CSMT in Peru: occurs in many places and in various forms, with transitions between different modalities. Sex work moreover involves people from varying social and economic backgrounds with motivations that go well beyond economic need. It is often associated with migration and specific economic activities; and has evolved in recent years with the mass dissemination of new media and communication technologies. In addition, new forms of commercial sex not been previously described in Peru, are growing up, especially in the cities of Iquitos and Pucallpa, and in the logging areas in the Peruvian Amazon.
In comparative terms, our data are consistent with recent studies in other countries. Some have proposed typologies of sex work based on explorations of the diverse forms of this practice between male and female sex workers (Buzdugan et al. 2010; Infante, Sosa-Rubi and Cuadra 2009). For example, one study identified 25 types of sex work practised in different countries (Harcourt and Donovan 2005). Other studies have described the forms of CSMT that take place in sexual entertainment establishments, or through the provision of private sexual companions (Aggleton 1999; Zuilhof 1999).
A number of factors identified in this study may help explain the diversity of CSMT in Peru. An important issue concerns the reasons that lead subjects of different sexual identities and socio-economical backgrounds to engage in sex work. Beyond economic necessity and its relative meanings, these include aspirations for consumption, social mobility and participation in elevated social circles. In this study we often encountered stories of subjects who were not ashamed to offer sexual services, and even saw this activity as preferable to other forms of work. Our research supports the findings from other work that argues that sex work may be a rational choice in pursuit of new income (Calhoun 1996), pleasure and fun (Weisberg 1985), and as an alternative to other forms of employment (Lukenbill 1985; Uy et al. 2004). The diversity and varied patterns of sex work practice encountered in this study are best explained by considering specific contexts and the confluence of individual, social, historical and structural factors (and not by focusing only on discrete “determinants” or isolated psychological traits).
In Peru, the HIV epidemic has been characterised as concentrated mainly in the urban populations of men who have sex with men (MSM), with HIV prevalence among such groups ranging from 15% to 18% and even up to 22% depending on sites, subgroups and methods of measurement (Bautista et al. 2004; Lama et al. 2006; Montano et al. 2005; Sanchez et al. 2007; Tabet et al. 2002). Data on sexual behaviour in these and other studies also show that exchange of sex for money or goods is relatively common among some groups of MSM (Caceres et al. 2008; Konda et al. 2008b; Valderrama et al. 2008), and that HIV occurs more frequently among those with more feminine identities (including travestis) and those who assume the passive (receptive) sex role in anal sex (Lama et al. 2006; Salazar et al. 2006; Tabet et al. 2002). Recent research has also detected high levels of HIV and STI in travestis receiving care at a clinic in Callao (Konda et al. 2008a), in different groups of sex workers in the Amazon (Valderrama et al. 2008), and among fletes in central Lima (A. Bayer, pers. comm., unpublished data).
While prior studies have reported rates of HIV/STI and data on sexual behaviour in the most visible forms of CSMT, the present research point to some of the diverse scenarios in which CSMT is practised in Peru. Given this diversity, we suggest that the most visible forms of CSMT are not necessarily the only ones that require attention as part of HIV/STI prevention activities. Although street-based fletes and travestis may be at greater risk for acquiring STIs and have higher social vulnerability, there is limited data regarding other newer or less visible modalities of CSMT. For instance, the widespread use of the internet and mobile phones in Peru now allow many sex workers to offer services outside the traditional public venues. While recent studies in the USA and Europe suggest there are significant differences between web-based and street-based sex work in terms of sexual practices and health risks (Cunningham and Kendall 2010), the implications of the use of new communication technologies for commercial sex remain unclear in Peru.
Our study shows the relationship between migration and sex work. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has emphasised that migrants often face unique situations, such as separation from family and friends, together with the constraints and social pressures associated with new environments, and less accessible health services. In the absence of the social norms of their home environment, some may adopt sexual practices they would not normally perform, thereby increasing the risk of acquiring and transmitting STIs (UNAIDS 2001). Many participants in our study reported similar situations and changes in behaviour. These issues need to be more deeply explored in future research on sex work in Peru.
We thank all study participants for their collaboration. This work was supported by the US National Institutes of Health through the International Clinical Research Fellows Program at Vanderbilt University (R24 TW007988) and the International AIDS Research & Training Program of the University of Washington. We also thank to Jerome T. Galea for his review of this paper, Ladislao Landa and Pablo Sandoval (Universidad Nacional Mayor de San Marcos) for their valuable comments on the study protocol, and the site leaders and personnel at Impacta, Inmensa (Lima), Asociación Civil Cayetano Heredia (Pucallpa), and Asociación Civil Selva Amazónica (Iquitos) for their support during the fieldwork. SM is an employee of the US Government. Her contribution to this work was part of her official duties. Title 17 U.S.C. §105 provides that Copyright protection under this title is not available for any work of the United States Government. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or positions of the US Government.